WEBVTT 1 00:00:00.000 --> 00:00:02.480 Today we're gonna be going over gastric disorders, so it's 2 00:00:02.480 --> 00:00:06.120 going to be involving gastritis, peptic ulcer disease, and pyloric stenosis. 3 00:00:06.400 --> 00:00:07.919 And I just want to mention really quick, if you 4 00:00:08.000 --> 00:00:10.800 do like the podcast, it's helping you. Please, please, if 5 00:00:10.800 --> 00:00:14.480 you wouldn't mind giving me a review on Apple Podcasts, Spotify, 6 00:00:14.599 --> 00:00:16.559 just let me know that it's helping you. It kind 7 00:00:16.559 --> 00:00:18.960 of also gets the word out about the podcast and 8 00:00:19.039 --> 00:00:21.559 helps other people discovered as well. I'd really appreciate that. 9 00:00:21.960 --> 00:00:23.800 So with that being said, let's go ahead and start 10 00:00:23.839 --> 00:00:27.920 with aqte gastritis. So qute gastritis is an inflammation resulting 11 00:00:27.920 --> 00:00:30.839 from gastric mucosal injury. It's important to note that there 12 00:00:30.920 --> 00:00:33.799 is something else called gastropathy, which is going to be 13 00:00:33.880 --> 00:00:37.799 a more superficial mucosal injury with no associated inflammation. So 14 00:00:37.840 --> 00:00:39.520 that's another term that you need to know as well. 15 00:00:39.640 --> 00:00:43.920 As far as eteologies, H pylori most common cause by 16 00:00:44.079 --> 00:00:46.679 far H pylori. Remember this is going to be your 17 00:00:46.679 --> 00:00:48.439 most common cause of acte gastritis. 18 00:00:48.719 --> 00:00:49.079 And H. 19 00:00:49.119 --> 00:00:52.600 Pylori is a GRAM negative bacteria that's very common. It's 20 00:00:52.600 --> 00:00:55.880 actually found in about half of the world's population, So 21 00:00:56.000 --> 00:00:58.759 not everybody gets symptoms from this though, So just because 22 00:00:58.759 --> 00:01:01.640 it's part of your microbio doesn't mean you're gonna have symptoms, 23 00:01:01.640 --> 00:01:04.879 but the people that do develop symptoms. H Pylori infects 24 00:01:04.879 --> 00:01:08.599 the gastric mucosa. It releases certain enzymes and toxins, and 25 00:01:08.680 --> 00:01:12.000 it injures the epithelial cells of the stomach, which leaves 26 00:01:12.040 --> 00:01:15.319 the stomach more vulnerable to the acid that's present and 27 00:01:15.480 --> 00:01:18.599 causes gastritis. It can cause peptic ulcers as well as 28 00:01:18.640 --> 00:01:21.079 pain and a number of other symptoms. So that's how 29 00:01:21.200 --> 00:01:23.879 H bilori causes that. Again, most common cause. That keep 30 00:01:23.959 --> 00:01:26.519 repeating it because it's important. And then your second most 31 00:01:26.560 --> 00:01:29.519 common cause is going to be from n seds and aspirin. 32 00:01:29.959 --> 00:01:33.280 So the way n seds and aspirin and cause gastritis 33 00:01:33.519 --> 00:01:36.319 one way is that it's just from a superficial irritation 34 00:01:36.480 --> 00:01:39.400 of the epithelium of the gastric mucosa. So that can 35 00:01:39.439 --> 00:01:42.400 happen if you take like eight hundred milligrams vibuprof and 36 00:01:42.439 --> 00:01:44.159 you didn't any food with it, and you just have 37 00:01:44.280 --> 00:01:47.040 this stomach pain for a couple hours. But the more 38 00:01:47.079 --> 00:01:51.359 important factor is that n sets inhibit COX one production, 39 00:01:51.840 --> 00:01:57.920 so COX one production is actually responsible for producing prostag landins. 40 00:01:58.120 --> 00:02:01.040 So if you decrease COX one production, decrease production of 41 00:02:01.079 --> 00:02:04.480 prostic landings. Well, why does that matter. It's because prostac 42 00:02:04.599 --> 00:02:09.240 landins actually inhibit gastric acid secretion, so less prostac landins 43 00:02:09.479 --> 00:02:13.800 means more gastric acid and more irritation like gastritis peptic ulcers. 44 00:02:13.840 --> 00:02:16.960 So that's why n sets are really important as a 45 00:02:17.000 --> 00:02:20.759 factor that can cause gastritis. And that's actually why n 46 00:02:20.879 --> 00:02:24.360 sets like celebres, which is also known as celocoxid, were 47 00:02:24.400 --> 00:02:29.680 created because celebres actually targets COX two rather than COX one, 48 00:02:29.919 --> 00:02:33.039 So this leads to less gastric issues and they have 49 00:02:33.080 --> 00:02:36.240 a number of other cardiovascular problems, but that's besides the point. 50 00:02:36.360 --> 00:02:38.879 But that's why they were created because when you don't 51 00:02:38.879 --> 00:02:41.240 target COX one, you don't affect the prostac landids in 52 00:02:41.240 --> 00:02:43.599 the stomach and you have less gastric problems. So that's 53 00:02:43.639 --> 00:02:46.479 why nc's are a big issue here. Some other less 54 00:02:46.479 --> 00:02:50.560 important causes are going to be alcohol, trauma, acute stress, 55 00:02:51.240 --> 00:02:53.439 radiation and things like that, but the ones you need 56 00:02:53.520 --> 00:02:56.639 to know is going to be h pylori and n sets. 57 00:02:56.680 --> 00:02:59.159 Do not forget those H pyloris You're most common and 58 00:02:59.319 --> 00:03:01.199 says you're second most common costs. 59 00:03:00.919 --> 00:03:01.560 So remember those. 60 00:03:01.599 --> 00:03:04.879 As far as the patient presentation, some patients initially may 61 00:03:04.919 --> 00:03:07.680 be asymptomatic, but as it progresses, you're going to have 62 00:03:07.719 --> 00:03:12.439 these non specific symptoms. It's like epigastric discomfort also known 63 00:03:12.479 --> 00:03:15.960 as dyspepsia. They may have some nausea, loss of appetite, 64 00:03:16.080 --> 00:03:18.479 nothing really specific that you need to know that's gonna 65 00:03:18.479 --> 00:03:21.000 stick out in a vignette, but just these non specific 66 00:03:21.039 --> 00:03:26.199 epigastric symptoms. Diagnosing while your test of choice, although it 67 00:03:26.240 --> 00:03:28.080 isn't necessarily going to be the first thing you do, 68 00:03:28.439 --> 00:03:30.400 is going to be an upper endoscopy. This is going 69 00:03:30.439 --> 00:03:34.439 to be your best test. But initially you're going to 70 00:03:34.520 --> 00:03:36.680 do some testing for H pylori because these are things 71 00:03:36.719 --> 00:03:39.120 that are non invasive. You can do a uria breath test, 72 00:03:39.120 --> 00:03:41.280 a fecal antigen test to test for H pylori to 73 00:03:41.319 --> 00:03:42.960 see if you need to treat that. I'll go over 74 00:03:43.000 --> 00:03:45.080 those tests a little bit in pepticals or disease and 75 00:03:45.479 --> 00:03:47.960 what they involve, but those so initially you probably test 76 00:03:48.000 --> 00:03:52.680 for h uria breath test fecal antigen test, and then eventually, 77 00:03:52.719 --> 00:03:55.280 if those tests come back negative, these patients are still 78 00:03:55.280 --> 00:03:58.280 having symptoms, you may move on to an upper endoscopy, 79 00:03:58.280 --> 00:04:01.080 which would be your best test. And this is going 80 00:04:01.120 --> 00:04:03.719 to be patients that are refractory to PPIs, H two 81 00:04:03.719 --> 00:04:05.479 blockers things like that. So some of the ways you 82 00:04:05.479 --> 00:04:10.319 can diagnose test for H pylori, upper endoscopy, and treatment, well, 83 00:04:10.360 --> 00:04:12.800 it all depends on the cause. So if these patients 84 00:04:12.840 --> 00:04:15.159 have H pylori, your test came back positive, you're your 85 00:04:15.280 --> 00:04:17.759 breath test or vecal antigen test came back positive. You're 86 00:04:17.759 --> 00:04:19.839 going to treat H pylori. So how do you treat 87 00:04:19.959 --> 00:04:23.160 H pyloria, whether it's quadruple therapy. Quadruple therapy is going 88 00:04:23.199 --> 00:04:27.160 to be a combination of PPIs, bismuth, metronidazol, and tetracycling. 89 00:04:27.240 --> 00:04:31.160 So H pylori positive treat the H pylori with quadruple therapy. 90 00:04:31.759 --> 00:04:33.759 You want to discontinue n SAID use if that's what's 91 00:04:33.800 --> 00:04:36.800 causing it, and you can also use PPIs and H 92 00:04:36.839 --> 00:04:41.519 two blockers, particularly in patients who require the continued use 93 00:04:41.560 --> 00:04:44.319 of n SET. So whether it's a cardiovascular patient that 94 00:04:44.360 --> 00:04:47.399 requires daily aspirin patient with chronic pain that has to 95 00:04:47.439 --> 00:04:50.360 take their ND sets but they develop gastritis, then you 96 00:04:50.399 --> 00:04:52.600 can use PPIs and H two blockers as well for 97 00:04:52.720 --> 00:04:56.600 the treatment. So treatment depends on the cause H pylori. 98 00:04:56.720 --> 00:04:59.480 Treat the H pylori discontinue n said use if they're 99 00:04:59.560 --> 00:05:02.160 using it, and PPIs and H two blockers are going 100 00:05:02.199 --> 00:05:02.759 to be your main. 101 00:05:02.639 --> 00:05:03.959 Ways to treat qute gastritis. 102 00:05:04.000 --> 00:05:05.639 As something else that I'm going to go over, it's 103 00:05:05.759 --> 00:05:07.879 definitely not very high yield, but you need to know 104 00:05:07.920 --> 00:05:10.560 that it exists because it is on the blueprint. It's 105 00:05:10.560 --> 00:05:15.279 something called autoimmune metaplastic atrophic gastritis, so again not high yield, 106 00:05:15.439 --> 00:05:18.000 but be aware that it exists. It's a chronic form 107 00:05:18.040 --> 00:05:22.800 of gastritis. It's an inherited autoimmune disease, so unlike a 108 00:05:22.920 --> 00:05:25.079 cute gastritis, this isn't going to be from N sets 109 00:05:25.160 --> 00:05:28.759 or it's pylori use. It's going to be an autoimmune process. 110 00:05:28.959 --> 00:05:31.800 So the immune system is actually attacking the parietal cells, 111 00:05:31.920 --> 00:05:34.360 an intrinsic factor in the body. This can lead to 112 00:05:34.399 --> 00:05:37.199 B twelve deficiency as well as this gastritis that these 113 00:05:37.199 --> 00:05:40.480 patients have. These patients are also at a high risk 114 00:05:40.920 --> 00:05:42.360 of gastric carcinoma. 115 00:05:42.839 --> 00:05:44.160 And one other important thing. 116 00:05:44.040 --> 00:05:46.800 That you need to know is that while acute gastritis 117 00:05:47.040 --> 00:05:50.680 most commonly affects the antrum of the stomach, chronic or 118 00:05:50.720 --> 00:05:54.480 autoimmune gastritis spares the antrum and most commonly affects the 119 00:05:54.519 --> 00:05:57.759 fundus or the body. So for real life maybe not 120 00:05:57.839 --> 00:06:01.600 so important, but for a vin yet they may mention that. 121 00:06:01.680 --> 00:06:05.920 So remember a QT gastritis affects the antrum, chronic autoimmune 122 00:06:06.000 --> 00:06:07.759 is going to most commonly affect the fundus in the 123 00:06:07.800 --> 00:06:10.160 body and spares the andantrum. That's really all you need 124 00:06:10.199 --> 00:06:12.120 to know for that. Don't go crazy again, not very 125 00:06:12.199 --> 00:06:12.680 high yield. 126 00:06:13.000 --> 00:06:13.959 Now moving on. 127 00:06:13.920 --> 00:06:16.439 To something that is high yield is peptic ulcer disease. 128 00:06:16.439 --> 00:06:17.560 So there's a lot of stuff you need to know 129 00:06:17.600 --> 00:06:19.040 on this. Let's go over that. There's going to be 130 00:06:19.079 --> 00:06:21.800 some overlap two with gastritis as well. So peptic ulcer 131 00:06:21.839 --> 00:06:26.480 disease encompasses both duodenal ulcers and gastric ulcers. So some 132 00:06:26.560 --> 00:06:28.399 things that two have in common, some things that help 133 00:06:28.439 --> 00:06:30.959 differentiate them. So we'll go over the different things. So 134 00:06:31.040 --> 00:06:34.279 let's start with duoden ulcers so duoden ulcers are going 135 00:06:34.319 --> 00:06:37.240 to be an area of erosion obviously in the duodenum. 136 00:06:37.439 --> 00:06:39.600 It's going to be your most common type, so much 137 00:06:39.639 --> 00:06:42.920 more common, about four times more common than gastric ulcers, 138 00:06:43.160 --> 00:06:46.399 and usually it's benign. Gastric Ulcers are going to be 139 00:06:46.600 --> 00:06:49.199 an area of erosion in the stomach, and these are 140 00:06:49.279 --> 00:06:53.680 less prevalent than duodenal ulcers and more commonly associated with 141 00:06:53.800 --> 00:06:58.279 gastric edinal carcinoma. So remember that duodenal ulcers usually benign. 142 00:06:58.399 --> 00:07:02.680 Gastric ulcers are more commonly associated with gastric adino carcinoma, 143 00:07:02.800 --> 00:07:05.600 and duoden ulcers are your more common type as far 144 00:07:05.639 --> 00:07:09.079 as eteologies, a lot of overlap here with gastritis. Again 145 00:07:09.360 --> 00:07:12.480 h pylori most common cause overall, nothing new that you 146 00:07:12.480 --> 00:07:15.360 need to know there, Second most common cause, N SAIDs 147 00:07:15.360 --> 00:07:18.160 an aspirin really easy. You already know this for gastritis, 148 00:07:18.360 --> 00:07:22.000 So again hpylori most common. N says an aspirin second 149 00:07:22.079 --> 00:07:24.959 most common. And then another odd bowl that you need 150 00:07:25.040 --> 00:07:27.800 to know of that's not very common about you know, 151 00:07:27.839 --> 00:07:30.360 like less than one percent of patients. It's something called 152 00:07:30.439 --> 00:07:35.160 Zollinger Ellison syndrome and This is a disease that produces 153 00:07:35.279 --> 00:07:40.040 high levels of gastrin from a neuroendocrine tumor, and gastrin 154 00:07:40.120 --> 00:07:42.079 leads to high levels of acid in the stomach, which 155 00:07:42.079 --> 00:07:44.639 can lead to ulcers and gastritis as well as another 156 00:07:44.800 --> 00:07:47.600 a few other things. So again not a very common cause, 157 00:07:47.600 --> 00:07:49.240 but something that you do need to know because it 158 00:07:49.240 --> 00:07:52.439 may come up in the boards, and just a small 159 00:07:52.519 --> 00:07:54.560 factor that you need to know as well. So hpylori 160 00:07:54.639 --> 00:07:56.279 is your most common cause overall, but it's going to 161 00:07:56.319 --> 00:07:59.879 be more associated with duodeno ulcers, where n sets an asper, 162 00:08:00.079 --> 00:08:02.240 your second most common cause overall is going to be 163 00:08:02.319 --> 00:08:05.360 more commonly associated with gaster cultures, So just know that, 164 00:08:05.439 --> 00:08:09.360 but again same overlap with gastritis. Hpylori most common, and 165 00:08:09.439 --> 00:08:11.560 sayd as an aspirin second most common, and then just 166 00:08:11.680 --> 00:08:15.000 know about zolinger ellison just as that oddball that may 167 00:08:15.000 --> 00:08:17.399 come up, as well as some of the other factors 168 00:08:17.439 --> 00:08:19.240 you know that can lead to pepic ulcers as well. 169 00:08:19.759 --> 00:08:23.240 Increased alcohol use, smoking also more common and elderly. Those 170 00:08:23.279 --> 00:08:25.120 are the less less important things that you need to know. 171 00:08:25.319 --> 00:08:27.920 But of course hpilor and SAIDs know those. Don't forget 172 00:08:27.959 --> 00:08:31.240 that as far as the history and exam, these patients 173 00:08:31.279 --> 00:08:36.399 are going to have some again non specific epigastric pain, burning, nausea, 174 00:08:36.440 --> 00:08:37.799 they may have early satiety. 175 00:08:38.159 --> 00:08:39.480 Those things aren't that important. 176 00:08:39.519 --> 00:08:42.000 It's not going to help you differentiate on of it and yet, 177 00:08:42.200 --> 00:08:44.120 But what you do need to know with this on 178 00:08:44.159 --> 00:08:47.679 the history and exam is the different presentation. Do oddinal 179 00:08:47.799 --> 00:08:51.360 ulcers are going to get better with food? Gastric ulcers 180 00:08:51.399 --> 00:08:54.200 are going to get worse with food. So why does 181 00:08:54.240 --> 00:08:58.000 that happen? Well, gastric cultures. When you eat, acids obviously 182 00:08:58.039 --> 00:09:00.240 released to help break down the food, and so the 183 00:09:00.320 --> 00:09:02.799 ulcers in the stomach you have pain right away. So 184 00:09:02.799 --> 00:09:05.799 as soon as you eat, immediately these patients start having pain, 185 00:09:06.159 --> 00:09:08.960 whereas duadinal ulcers obviously a little bit further down the 186 00:09:08.960 --> 00:09:12.080 GI tract. As you're eating, the food's kind of shut down, 187 00:09:12.159 --> 00:09:14.840 it's clamped off, it's churning up in there trying to 188 00:09:14.840 --> 00:09:17.440 break down the food. So all the acids in the stomach, 189 00:09:17.840 --> 00:09:19.840 but it's not until about two to five hours later 190 00:09:19.879 --> 00:09:22.600 that the food starts to be released from the stomach 191 00:09:22.840 --> 00:09:26.399 enters the duodom. Now these patients start to have pain. 192 00:09:26.799 --> 00:09:29.159 So while these patients are eating and they have a 193 00:09:29.240 --> 00:09:31.399 duodin ulcer. They have some relief for about two to 194 00:09:31.480 --> 00:09:34.440 five hours while the acids still sitting in the stomach. 195 00:09:34.480 --> 00:09:36.120 Once it starts to come out, then they have pain. 196 00:09:36.480 --> 00:09:39.799 So duodenal ulcers they're gonna have, They're gonna have relief 197 00:09:40.200 --> 00:09:43.759 with food. They're gonna see their symptoms improved. Duadinals are 198 00:09:43.759 --> 00:09:46.000 going to be better with food. Gastric is gonna be 199 00:09:46.000 --> 00:09:49.320 worse with food. The way I remember that duodenal ulcers. 200 00:09:49.480 --> 00:09:52.360 Du I remember, dude, give me food? 201 00:09:52.639 --> 00:09:53.320 Do you do? 202 00:09:54.039 --> 00:09:56.639 Just like in dude and duodenal? Dude give me food? 203 00:09:57.039 --> 00:09:59.919 So better with food, duodonal ulcers and gastric. 204 00:09:59.559 --> 00:10:00.600 Is worse with food. 205 00:10:00.879 --> 00:10:04.559 And that's why patients with gastric ulcers that the pain 206 00:10:04.600 --> 00:10:06.320 gets worse with eating. A lot of times you'll see 207 00:10:06.320 --> 00:10:09.519 weight loss in these individuals compared to duaden ulcers. You 208 00:10:09.559 --> 00:10:13.200 may see weight gain because their symptoms get better with food, 209 00:10:13.279 --> 00:10:15.200 so they tend to eat more, So it makes sense. 210 00:10:15.480 --> 00:10:16.360 One other thing to be. 211 00:10:16.360 --> 00:10:19.799 Mindful of is that peptic ulcers can bleed and they 212 00:10:19.799 --> 00:10:22.919 can also perforate, So you need to know that peptic 213 00:10:23.000 --> 00:10:26.759 ulcers are actually peptic ulcer disease is the most common 214 00:10:27.159 --> 00:10:30.399 cause of an upper GI bleed. Peptic Ulcer disease most 215 00:10:30.440 --> 00:10:32.840 common cause of an upper GI bleed. And in the 216 00:10:32.879 --> 00:10:35.759 case that they do perforate, these patients are going to 217 00:10:35.840 --> 00:10:39.159 go from this kind of vague epigastric pain pepsia blah 218 00:10:39.200 --> 00:10:43.200 blah blah, to this sudden onset of this sharp, acute 219 00:10:43.240 --> 00:10:46.399 abdominal pain. They may have signs of peritonitis like rebound 220 00:10:46.440 --> 00:10:50.320 tenderness guarding. So know that these peptic ulcers can perforate, 221 00:10:50.399 --> 00:10:52.559 they can bleed, and the presentation is going to be 222 00:10:52.639 --> 00:10:55.080 much different. It's obviously a much more serious situation as 223 00:10:55.120 --> 00:10:59.159 far as diagnosing. Ultimately, your most sensitive and specific test 224 00:10:59.279 --> 00:11:01.799 is going to be in an endoscopy, But there's a 225 00:11:01.840 --> 00:11:03.279 few things you want to do before you get to 226 00:11:03.320 --> 00:11:07.000 an endoscopy. But remember, if an endoscopy is on the 227 00:11:08.000 --> 00:11:10.440 answer listen it says what is your best test endoscopy, 228 00:11:10.480 --> 00:11:12.720 it's always going to be the endoscopy. But in real life, 229 00:11:12.759 --> 00:11:14.039 there's a few things that you're going to do first 230 00:11:14.080 --> 00:11:16.279 and a few other tests. So if it says what's 231 00:11:16.320 --> 00:11:18.480 your initial test, you may go with some other things. 232 00:11:18.480 --> 00:11:20.759 So let's go over that Initially you're probably going to 233 00:11:20.840 --> 00:11:22.559 test for H. Pylori, So you can do that a 234 00:11:22.600 --> 00:11:24.679 couple of different ways. You can do a urrea breath 235 00:11:24.720 --> 00:11:28.200 test or an H. Pylori stool antigen H pylori testing. 236 00:11:28.200 --> 00:11:30.120 When you do a uria breath test, what you need 237 00:11:30.120 --> 00:11:33.639 to know about this is is that H. Pylori produces 238 00:11:33.679 --> 00:11:38.480 an enzyme called urease, which breaks down urrea into ammonia 239 00:11:38.519 --> 00:11:41.360 and carbon dioxide. So the way this test works is 240 00:11:41.399 --> 00:11:43.679 that during the test, the patient is given a pill 241 00:11:43.720 --> 00:11:46.919 containing urea and then they blow into this bag. They 242 00:11:46.960 --> 00:11:48.799 blow into the bag, they close off the bag, it's 243 00:11:48.799 --> 00:11:50.240 sent to a lab, and then they test for the 244 00:11:50.279 --> 00:11:53.240 amount of exhaled carbon dioxide. And remember again they were 245 00:11:53.240 --> 00:11:56.960 given urea, and as I said before, H pylori turns 246 00:11:57.120 --> 00:11:59.480 urea into carbon dioxide and ammonia. So if there's an 247 00:11:59.480 --> 00:12:02.000 increase in all this carbon dioxide that's in this bag, 248 00:12:02.159 --> 00:12:04.240 then obviously this is gonna be a positive test for H. 249 00:12:04.240 --> 00:12:04.639 Pylori. 250 00:12:04.720 --> 00:12:07.960 So that's how a urrea breath test works. H Pylori 251 00:12:08.000 --> 00:12:10.799 stool intogen is straightforward. It's literally just checking for a 252 00:12:10.840 --> 00:12:11.840 stool antigen of H. 253 00:12:11.840 --> 00:12:12.240 Pylori. 254 00:12:12.399 --> 00:12:14.120 So that's another test that you can do as well. 255 00:12:14.360 --> 00:12:16.840 And then ultimately, like I said before, the gold standard 256 00:12:16.879 --> 00:12:19.840 test is going to be your endoscopy. That's going to 257 00:12:19.879 --> 00:12:21.759 be to diagnose. You can visualize the ulcer and you 258 00:12:21.799 --> 00:12:24.919 can take biopsies if needed, and then treatment depends on 259 00:12:24.960 --> 00:12:28.000 the cause. So let's start with H pylori. If this 260 00:12:28.080 --> 00:12:31.840 patient is H pylori positive, again, just like in guesstritis, 261 00:12:31.919 --> 00:12:34.440 you're going to do quadruple therapy. The way I remember 262 00:12:34.519 --> 00:12:38.159 quadruple therapy for an hpylori positive patient is I remember 263 00:12:38.480 --> 00:12:41.600 these patients have belly pain. They want you to treat 264 00:12:41.600 --> 00:12:43.399 their belly pain so they can get better. So they 265 00:12:43.440 --> 00:12:47.840 say to you, treat my belly, please, treat my belly please. 266 00:12:48.279 --> 00:12:55.000 TMBP that stands for tetracycling, metronideisol, bismyth subseliciy, and PPIs 267 00:12:55.120 --> 00:12:59.480 treat my belly please. Tetracycling, metronide, is al, bismuth, subselicily, 268 00:12:59.639 --> 00:13:03.159 and P. Those are for your H. Pylori positive patients. Now, 269 00:13:03.159 --> 00:13:05.840 if these patients are hpylori negative, how do you treat 270 00:13:05.840 --> 00:13:08.919 their peptic ulcer disease? Well, first, treat the underlying cause. 271 00:13:09.399 --> 00:13:13.240 If they're taking nsids, they're smokers, they drink a bunch 272 00:13:13.240 --> 00:13:16.039 of alcohol. You're going to discontinue all those things obviously, 273 00:13:16.519 --> 00:13:19.039 and then you're going to give them PPIs as well. 274 00:13:19.879 --> 00:13:24.000 You can also use H two blockers, but realistically, anytime 275 00:13:24.039 --> 00:13:25.919 you have an option of a PPI or an H 276 00:13:26.000 --> 00:13:30.519 two blocker, unless there's some contraindication of PPIs, always use PPIs. 277 00:13:30.840 --> 00:13:34.639 Why is that PPIs are much more effective, and that's because, 278 00:13:34.799 --> 00:13:37.000 I mean, just really quickly break down the way these 279 00:13:37.039 --> 00:13:38.639 work and just to give you a little bit about 280 00:13:38.679 --> 00:13:41.440 the may of the mets. So you have a parietal 281 00:13:41.519 --> 00:13:44.799 cell in the stomach. The parietal cell has a proton pump. 282 00:13:44.919 --> 00:13:47.759 That's what shoots out all the hydrochloric acid into the stomach. 283 00:13:48.039 --> 00:13:50.399 That's where all of your acid in the stomach comes from. 284 00:13:50.759 --> 00:13:54.440 So how is your prietal cell activated. Well, acetylcholine, histamine, 285 00:13:54.440 --> 00:13:58.279 and gastrin all activate the prietal cell to pump out 286 00:13:58.279 --> 00:14:02.320 this acid. An H CH two blocker obviously blocks H 287 00:14:02.440 --> 00:14:05.639 two and that's histamine, So that's a histamine blocker, So 288 00:14:05.720 --> 00:14:09.360 it blocks just histamine, but you still have acetocholine and 289 00:14:09.399 --> 00:14:12.480 gastrine that can activate the parietal cell. So while it 290 00:14:12.639 --> 00:14:15.879 helps because you stop the histamine from activating the paryal cell. 291 00:14:16.039 --> 00:14:18.840 Stylcholine and gastrine are still working there to pump out acid, 292 00:14:19.039 --> 00:14:22.159 so there's still some acid production, Whereas a proton pump 293 00:14:22.159 --> 00:14:26.200 inhibitor actually completely shuts off the proton pump, so it 294 00:14:26.200 --> 00:14:28.639 doesn't matter how much is stylcholine, how much histamine, how 295 00:14:28.679 --> 00:14:32.120 much gastrine is activating that parietal cell. The pump is 296 00:14:32.159 --> 00:14:35.159 shut off, so no acids coming out. So PPIs are 297 00:14:35.240 --> 00:14:37.440 much more effective. So remember, if you have an option 298 00:14:37.519 --> 00:14:40.159 of a PPI or hto blocker, use the PPI. So 299 00:14:40.200 --> 00:14:44.080 again H pylor negative, treat the underlying cause, give them PPIs. 300 00:14:44.360 --> 00:14:47.279 That's the treatment. If they're H pylori positive, treat the 301 00:14:47.399 --> 00:14:50.639 H pylori very easy treatment. And then there's one other 302 00:14:50.679 --> 00:14:54.480 treatment option that you should probably know. For refractory patients. 303 00:14:54.519 --> 00:14:58.679 The PPIs aren't working, you discontinued all the ensis, et cetera, 304 00:14:58.960 --> 00:15:01.320 and they're still having SIN, you can do something called 305 00:15:01.320 --> 00:15:04.519 the parietal cell veagotomy, which is where they sever the 306 00:15:04.600 --> 00:15:09.000 vagual nerve, which essentially shuts down the portion of the 307 00:15:09.039 --> 00:15:12.440 stomach where the parietal cells are located. And this obviously 308 00:15:12.519 --> 00:15:15.759 leads to decreased acid by about seventy five percent, So 309 00:15:15.799 --> 00:15:18.639 pretty effective procedure, but it's invasive. Obviously, there's a lot 310 00:15:18.679 --> 00:15:20.320 of things you want to try before you get to 311 00:15:20.360 --> 00:15:22.240 a parietal cell vegotamin. This is just going to be 312 00:15:22.240 --> 00:15:25.080 for your refractory patients. So those are the treatments. Let's 313 00:15:25.120 --> 00:15:26.879 move on to the home stretch here. The last thing 314 00:15:26.879 --> 00:15:28.039 we're going to go over, and that's going to be 315 00:15:28.039 --> 00:15:30.720 pyloric stenosis. So this is going to be a condition 316 00:15:30.960 --> 00:15:33.879 commonly in newborns. About three to six weeks is going 317 00:15:33.919 --> 00:15:36.279 to be your most common age range, and it's a 318 00:15:36.320 --> 00:15:42.000 thickening hypertrophy, a thickening or hypertrophy of the pyloris, which 319 00:15:42.039 --> 00:15:45.080 is the sphincter, the muscular valve between the stomach and 320 00:15:45.120 --> 00:15:49.399 the duodenum, so it prevents gastric emptying. Risk factors are 321 00:15:49.440 --> 00:15:52.399 going to be males four times more common in male, 322 00:15:52.480 --> 00:15:55.200 so definitely know that males are going to be much 323 00:15:55.200 --> 00:15:58.279 more common. Look at your vignette. If it's a female, 324 00:15:58.720 --> 00:16:00.519 you know for a vignette probably and that's so common 325 00:16:00.519 --> 00:16:03.000 that it's going to be pylar scinosis. Three to six 326 00:16:03.039 --> 00:16:05.360 weeks is going to be your most common age of presentation. 327 00:16:05.720 --> 00:16:08.440 Sometimes they'll say three to twelve, but generally three to 328 00:16:08.480 --> 00:16:11.519 six is the most common. And then first born patients 329 00:16:11.519 --> 00:16:13.240 are also going to be at a higher risk. And 330 00:16:13.279 --> 00:16:15.919 then the last thing too, not as you know, not 331 00:16:15.960 --> 00:16:17.639 as big of a risk as the other ones, but 332 00:16:17.799 --> 00:16:22.279 macrolide antibiotics, in particular erythromycin within the first two weeks 333 00:16:22.720 --> 00:16:26.200 of birth can also lead to pyloric stenosis. And this 334 00:16:26.360 --> 00:16:29.600 is the way it's explained, is most likely due to 335 00:16:29.639 --> 00:16:33.840 the increased gastric motility with macrolight antibiotics. Erythromycin, even a 336 00:16:33.919 --> 00:16:37.240 zythromycin can cause this. So the increased gastric motility in 337 00:16:37.279 --> 00:16:40.279 these drugs can lead to hypertrophy from the pyloris basically 338 00:16:40.320 --> 00:16:43.200 just being overworked. And it's the same reason that we 339 00:16:43.320 --> 00:16:47.360 use erythromycin and gastroparesis because it increases the gimotility. So 340 00:16:47.399 --> 00:16:49.480 if you have a patient under two weeks they give 341 00:16:49.519 --> 00:16:52.200 them a erythromycin, this may lead to pyloric stenosis. So 342 00:16:52.279 --> 00:16:55.639 risks again males first born three to six weeks of 343 00:16:55.679 --> 00:16:59.240 life and macrolide antibiotics in particular erythromycin. All right, So 344 00:16:59.519 --> 00:17:02.559 as far as the history and the exam. They may 345 00:17:02.600 --> 00:17:06.599 have some non specific symptoms weight loss, dehydration doesn't matter. 346 00:17:06.680 --> 00:17:08.319 You don't care about that stuff because it's not going 347 00:17:08.359 --> 00:17:11.079 to help you differentiate it in Yet, what you need 348 00:17:11.119 --> 00:17:14.079 to know for pylor ex stenosis, there's two really big 349 00:17:14.119 --> 00:17:19.359 things you cannot forget. So pilar stenosis non bilious projectile 350 00:17:19.440 --> 00:17:22.160 vomiting after feeding. That is going to be your vignette 351 00:17:22.240 --> 00:17:24.400 right there. You can just go ahead and circle pilar stenosis. 352 00:17:24.480 --> 00:17:26.440 That's gonna be your answer. So you see non bilious 353 00:17:26.440 --> 00:17:29.839 projectile vomiting after feeding pilar stenosis. So why is it 354 00:17:29.960 --> 00:17:33.599 non bilious? Well, remember this is an obstruction at the stomach. 355 00:17:33.640 --> 00:17:36.519 It's at the pylorus, so we're not into the area 356 00:17:36.519 --> 00:17:38.759 where the bile is coming from the common bioduct. It's 357 00:17:38.799 --> 00:17:41.880 not evolves. It's an unomal rotation of the small bowel, 358 00:17:41.920 --> 00:17:43.559 so we're not in the area where the bile is 359 00:17:43.599 --> 00:17:46.839 being excreted. So it's gonna be non bilious. It's in 360 00:17:46.880 --> 00:17:50.200 the stomach, So non bilious projectile vomiting after feeding that 361 00:17:50.359 --> 00:17:53.359 is going to be pathonomoonic, almost as pathonomonic as The 362 00:17:53.400 --> 00:17:55.119 second thing you need to know for the exam and 363 00:17:55.160 --> 00:17:58.000 that's going to be an olive shaped mass. So on 364 00:17:58.079 --> 00:18:01.720 physical exam, we talked about the the pyloris being hypertropheed. 365 00:18:01.759 --> 00:18:04.960 It's enlarged, and on physical exam, normally you're not gonna 366 00:18:04.960 --> 00:18:07.119 be able to feel the pylorus. But these patients, because 367 00:18:07.119 --> 00:18:10.599 it's hypertrop feed, you're actually going to feel this olive 368 00:18:10.640 --> 00:18:14.440 shaped mass in the epigastric area and it's going to 369 00:18:14.480 --> 00:18:16.759 feel like a small round mass and it's described as 370 00:18:16.799 --> 00:18:20.559 an olive shaped mass. If you see this on a vignette, 371 00:18:20.680 --> 00:18:22.559 you see this or you feel this in real life, 372 00:18:22.599 --> 00:18:25.640 this is really pathdomonic for the disease. And actually, years ago, 373 00:18:25.720 --> 00:18:29.680 before ultrasound was around, this would be the only way 374 00:18:29.680 --> 00:18:31.720 you would diagnose it. If you felt this olive shaped mass, 375 00:18:31.720 --> 00:18:34.000 they would go right to surgery, you know, after you 376 00:18:34.119 --> 00:18:36.720 treated them with fluids and things like that. So physical 377 00:18:36.759 --> 00:18:41.119 exam no non bilious projectile vomiting and no olive shaped mass. 378 00:18:41.119 --> 00:18:42.440 So those are the two things you need to know 379 00:18:42.559 --> 00:18:45.319 as far as diagnosing. Ultrasound is going to be your 380 00:18:45.359 --> 00:18:48.240 test of choice. It's ninety seven to ninety nine percent 381 00:18:48.400 --> 00:18:50.079 sensitive no radiation. 382 00:18:50.160 --> 00:18:50.920 These are newborns. 383 00:18:50.920 --> 00:18:52.440 You really don't want to radiate them if you don't 384 00:18:52.480 --> 00:18:54.400 have to. And then on the ultrasound, you're going to 385 00:18:54.440 --> 00:18:58.119 see some pyloric muscle thickness over four millimeters and the 386 00:18:58.160 --> 00:19:00.960 pyloric canal length will be over seven eighteen millimeters. Don't 387 00:19:00.960 --> 00:19:03.079 worry about those numbers, but I just want to throw 388 00:19:03.119 --> 00:19:05.200 that out there so you know that's how you actually 389 00:19:05.400 --> 00:19:06.559 have a positive ultrasound. 390 00:19:06.559 --> 00:19:08.200 But ultra sound is gonna be your test of choice. 391 00:19:08.240 --> 00:19:09.839 The only reason I'm even going to mention an upper 392 00:19:09.839 --> 00:19:11.559 GI series not so much that you're going to use 393 00:19:11.559 --> 00:19:12.920 it in real life. It's really only going to be 394 00:19:12.920 --> 00:19:17.079 if ultrasounds inconclusive, the physical exam is inconclusive. But you 395 00:19:17.160 --> 00:19:18.960 need to know for the exam because on an upper 396 00:19:18.960 --> 00:19:21.000 GI series, there's a couple of key terms. 397 00:19:21.200 --> 00:19:22.759 There's one called a string sign. 398 00:19:22.799 --> 00:19:26.200 It's not specific only to pyloxynosis, but if you do 399 00:19:26.279 --> 00:19:28.559 see it in this vignette, this is going to be 400 00:19:28.599 --> 00:19:32.000 a narrowed area of barium flow. It's literally going to 401 00:19:32.079 --> 00:19:35.160